CASE A1 Hypoglycemia in an Elderly T2DM Patient with Heart Failure

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1 Hypoglycemia in an Elderly T2DM Patient with Heart Failure 1

2 I would like to introduce you to Sophie, an elderly patient with long-standing type 2 diabetes, who has a history of heart failure, a common presentation in clinical practice, as many individuals with diabetes also have cardiovascular disease. In addition, diabetes increases the risk of heart failure independent of coronary heart disease. 2

3 Sophie is brought to the office by her daughter. During the course of our discussions, I began to suspect that Sophie might also be experiencing hypoglycemia related to her current medication regimen. 3

4 Let s summarize the key considerations from this case. Sophie has hypoglycemia, renal insufficiency, and cardiovascular disease with heart failure. We need to examine the risk factors for the hypoglycemia, and when determining the most appropriate therapy for this patient, have to keep in mind which drugs might require a dosage adjustment and which drug classes should be avoided completely. 4

5 Here, we see many of the risk factors for hypoglycemia in elderly patients with type 2 diabetes. 5

6 This slide illustrates the association between medication-related hypoglycemia and vascular risk. There was a significantly greater cumulative three-year incidence of both cardiovascular disease and microvascular complications in patients with hypoglycemia. 6

7 This slide illustrates the ADA/EASD General Recommendations for the management of our patients with diabetes. 7

8 In a patient such as Sophie who has had episodes of hypoglycemia, we should follow the adapted recommendations illustrated on this slide, avoiding sulfonylureas and insulin. 8

9 We also need to take into consideration that adverse events associated with TZD treatments, including weight gain and fluid retention, are significant concerns in a patient like Sophie who already has congestive heart failure. 9

10 PROACTIVE demonstrated that pioglitazone reduces the composite of all-cause mortality, nonfatal MI, and stroke. However, six percent of those in the pioglitazone group, compared with four percent of those in the placebo group, were admitted to the hospital with heart failure. 10

11 SGLT-2 inhibitors block the reabsorption of filtered glucose by the proximal tubules of the kidney, leading to glycosuria and improved glycemic control. This class of drugs has multiple additional benefits including weight loss and decreased blood pressure. Their action complements the action of other anti-diabetic agents and, because they are independent of insulin, are associated with low rates of hypoglycemia. 11

12 Sophie also has impaired renal function with an EGFR of 28 milliliters per minute. This slide lists the necessary dosage adjustments and contraindications of the drugs used to treat type 2 diabetes in patients with renal impairment. 12

13 Of the recommended options for this patient, the DPP-4 inhibitor class is associated with the fewest cautions and is associated with the lowering of the hemoglobin A1c of up to 0.9 percent. 13

14 In determining the optimal management of Sophie s case, we must consider her specific presentation to individualize her treatment. She has hypoglycemia, a risk in our older individuals, especially those with comorbidities. We should discontinue the glipizide and avoid the use of insulin. In addition, it is very important that she now be assisted with a balanced diet to avoid hypoglycemia due to skipped meals. Because of her history of heart failure, a TZD would be contraindicated. There is some new data from the SAVOR-TIMI Study suggesting that treatment with DPP-4 inhibitors, especially saxagliptin, is associated with an increased risk of heart failure. Because Sophie also has a renal insufficiency, treatment with metformin is contraindicated, and SGLT-2 inhibitors would not be effective. Most of the DPP-4 inhibitors, with the exception of linagliptin, require a dose adjustment based on a GFR. Taking into consideration all of her comorbidities, the optimal treatment for this patient would be a GLT-1 receptor agonist in conjunction with the therapeutic lifestyle changes we discussed earlier. 14

15 This slide lists some clinical tips for preventing hypoglycemia in our patients with type 2 diabetes. 15

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